Referral Creation Wizard

Complete the following referral form to submit a request for counselling at Riverside Counselling Service .


Personal Information

Enter the client's forename.
Enter the client's surname.
Enter a contact number for appointments.
Enter an email address for appointments.


Please enter the client's date of birth (format: dd/MM/yyyy)
If client is under 16, please enter a parent/guardian's name and contact number.
Please select the clients gender.

Address Information

Enter a street and house number.
Optionally enter a town.
Optionally, select a country.
Optionally, select a county.
Enter the first part of the postcode (e.g MK6)
Enter the second part of the postcode (e.g 5LP)


Are ground floor facilities required?
If they are, please provide some detail regarding this.
Please select any special requirements you might need (Select all applicable).
Please select a location
Please select a project below. Please make sure you are eligible otherwise your referral may be cancelled.
Please select a service.
Who told you to make a counselling request? If you are a professional making a referral please enter where you are from.
Enter the current school being attended if applicable.


Please give a brief summary of why support is required (including any relevant medical/family history).
Please give a brief summary of when you are available.
Please enter some additional information.
Select one or more of the issues you are experiencing.
Please select a how did you hear about us option
Please tick if you have previously seen one of our Counsellors?
If you have used the service before, please give us some details on this.

GP and Referrer

General Practitioner Details

Please select an existing GP from the list below.
If your general practitioner doesn't exist in the list above tick this checkbox and complete the new GP form.

Referrer Details

Please select an existing referrer from the list below.
If your referrer doesn't exist in the list above tick this checkbox and complete the new referrer form.

Family Members

Contact Information

Tick if this family member may attend appointments.
Enter family members forename.
Enter family members surname.
Enter family members email address.
Enter family members date of birth.
Select the family members relationship.
Select the family members gender.
Enter family members contact number.
Please enter a contact number

Address Information

Tick if you would like to copy the address from the primary client.
Enter a street and house number.
Please enter a street
Optionally enter a town.
Please enter a town
Select a country
Please select a country
Select a county
Please select a county
Enter postcode area.
Please enter an area code
Enter postcode.
Please enter an postcode
  • No family members added.


How we use client information

In order to provide an effective and professional counselling service, Riverside holds information about you, which includes contact details, information about your GP, date of birth, source of referral, previous experience of counselling and medication used and a brief session note. Your personal data will not be shared with anyone outside Riverside without your knowledge and permission, unless any of the following apply:

1 When a counsellor has good grounds for believing that a person may cause serious harm to themselves or others.

2 When we are instructed by a court to disclose information.

3. When a person discloses serious criminal activity, or knowledge of serious criminal activity, this includes statutory obligations in relation to terrorist activity and is a legal requirement.

4 When it is necessary to uphold child protection laws.

Your personal data is usually held by Riverside for 7 years after you have finished counselling.

Riverside is accredited by the British Association for Counselling and Psychotherapy (BACP) and all our counsellors comply with the BACP’s Ethical Framework for the Counselling Professions. In accordance with their professional requirements, counsellors discuss their work with an external supervisor, but the identity of the client is not revealed. Case material may sometimes be used anonymously by counsellors to enhance their practice and professional development. Anonymised data is used for the purposes of accounting, fundraising, preparing annual reports, publicising Riverside’s work, raising awareness and research. You can ask to see the information held about you at any time and a data subject access request will be responded to within 30 days of your request.

Your responsibility

We would ask that you keep us informed (by email, telephone, or in writing) of any changes in your personal data so that we may have our records up to date at all times. If you wish to withdraw your consent please contact us (by email, telephone, or in writing). You have the ‘right to be forgotten’, which means you can request the deletion or removal of personal data where there is no compelling reason for its continued processing.

Access permission

I consent that you can share details with my GP and other 3ʳᵈ parties who are involved in the contract entered into by you and us

Communication Permission

I consent that I'd like to hear from you via email

I consent that I'd like to receive SMS texts from you

I consent that I'd like to receive letters from you

I consent that I'd like to receive phone calls from you and you can leave voice messages

Leave unchecked and we will NOT contact you via this method, a minimum of ONE consent must be given.